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1.  Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership 
Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs).
To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.
In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.
The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.
PMCID: PMC2834925  PMID: 20216954
bottom-up process; leadership; change practices; services arrangements
2.  L'évaluation de l'autonomie fonctionnelle des personnes, âgées 
Canadian Family Physician  1982;28:754-762.
Care of the aged necessitates a functional diagnosis, with which physicians have little familiarity. The author reviews the principles of autonomy and dependence, applying them to the health care context. He proposes a method of sifting the necessary factors in measuring functional autonomy in elderly people.
PMCID: PMC2306554  PMID: 21286203
3.  Supervision, support and mentoring interventions for health practitioners in rural and remote contexts: an integrative review and thematic synthesis of the literature to identify mechanisms for successful outcomes 
To identify mechanisms for the successful implementation of support strategies for health-care practitioners in rural and remote contexts.
This is an integrative review and thematic synthesis of the empirical literature that examines support interventions for health-care practitioners in rural and remote contexts.
This review includes 43 papers that evaluated support strategies for the rural and remote health workforce. Interventions were predominantly training and education programmes with limited evaluations of supervision and mentoring interventions. The mechanisms associated with successful outcomes included: access to appropriate and adequate training, skills and knowledge for the support intervention; accessible and adequate resources; active involvement of stakeholders in programme design, implementation and evaluation; a needs analysis prior to the intervention; external support, organisation, facilitation and/or coordination of the programme; marketing of the programme; organisational commitment; appropriate mode of delivery; leadership; and regular feedback and evaluation of the programme.
Through a synthesis of the literature, this research has identified a number of mechanisms that are associated with successful support interventions for health-care practitioners in rural and remote contexts. This research utilised a methodology developed for studying complex interventions in response to the perceived limitations of traditional systematic reviews. This synthesis of the evidence will provide decision-makers at all levels with a collection of mechanisms that can assist the development and implementation of support strategies for staff in rural and remote contexts.
PMCID: PMC3944003  PMID: 24521004
Supervision; professional development; synthesis; mechanism; health practitioner; rural
4.  A mixed methods multiple case study of implementation as usual in children’s social service organizations: study protocol 
Improving quality in children’s mental health and social service settings will require implementation strategies capable of moving effective treatments and other innovations (e.g., assessment tools) into routine care. It is likely that efforts to identify, develop, and refine implementation strategies will be more successful if they are informed by relevant stakeholders and are responsive to the strengths and limitations of the contexts and implementation processes identified in usual care settings. This study will describe: the types of implementation strategies used; how organizational leaders make decisions about what to implement and how to approach the implementation process; organizational stakeholders’ perceptions of different implementation strategies; and the potential influence of organizational culture and climate on implementation strategy selection, implementation decision-making, and stakeholders’ perceptions of implementation strategies.
This study is a mixed methods multiple case study of seven children’s social service organizations in one Midwestern city in the United States that compose the control group of a larger randomized controlled trial. Qualitative data will include semi-structured interviews with organizational leaders (e.g., CEOs/directors, clinical directors, program managers) and a review of documents (e.g., implementation and quality improvement plans, program manuals, etc.) that will shed light on implementation decision-making and specific implementation strategies that are used to implement new programs and practices. Additionally, focus groups with clinicians will explore their perceptions of a range of implementation strategies. This qualitative work will inform the development of a Web-based survey that will assess the perceived effectiveness, relative importance, acceptability, feasibility, and appropriateness of implementation strategies from the perspective of both clinicians and organizational leaders. Finally, the Organizational Social Context measure will be used to assess organizational culture and climate. Qualitative, quantitative, and mixed methods data will be analyzed and interpreted at the case level as well as across cases in order to highlight meaningful similarities, differences, and site-specific experiences.
This study is designed to inform efforts to develop more effective implementation strategies by fully describing the implementation experiences of a sample of community-based organizations that provide mental health services to youth in one Midwestern city.
PMCID: PMC3751866  PMID: 23961701
Implementation strategies; Mental health; Children and adolescents; Mixed methods; Multiple case study
5.  Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people 
BMC Geriatrics  2011;11:24.
Frail elderly people need an integrated and coordinated care. The two-armed study "Continuum of care for frail elderly people" is a multi-professional and multidimensional intervention for frail community-dwelling elderly people. It was designed to evaluate whether the intervention programme for frail elderly people can reduce the number of visits to hospital, increase satisfaction with health and social care and maintain functional abilities. The implementation process is explored and analysed along with the intervention. In this paper we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants.
The study is a randomised two-armed controlled trial with follow ups at 3, 6 and 12 months. The study group includes elderly people who sought care at the emergency ward and discharged to their own homes in the community. Inclusion criteria were 80 years and older or 65 to 79 years with at least one chronic disease and dependent in at least one activity of daily living. Exclusion criteria were acute severely illness with an immediate need of the assessment and treatment by a physician, severe cognitive impairment and palliative care. The intention was that the study group should comprise a representative sample of frail elderly people at a high risk of future health care consumption. The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process.
The design of the study, the randomisation procedure and the protocol meetings were intended to ensure the quality of the study. The implementation of the intervention programme is followed and analysed throughout the whole study, which enables us to generate knowledge on the process of implementing complex interventions. The intervention contributes to early recognition of both the elderly peoples' needs of information, care and rehabilitation and of informal caregivers' need of support and information. This study is expected to show positive effects on frail elderly peoples' health care consumption, functional abilities and satisfaction with health and social care.
Trial registration NCT01260493
PMCID: PMC3118103  PMID: 21569570
6.  The PRISMA France study: implementation rate and factors influencing this rate 
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. In the PRISMA-France study, we qualitatively studied the implementation process of this model in French settings.
Our analyses were based on in-depth interviews, meeting observations and the documentation produced.
We adapted the implementation scale inherent to the PRISMA model to fit the French context and, using this scale, were able to appreciate a 15% progression of implementation, from 5% to 20%, in the first 18 months of the study. The factors that contributed to this rate of progression are of three main types. To begin with, contextual factors intrinsic to the French setting complexified the incorporation of integration into the public policy agenda and the means to achieve this feat. Secondly, factors related to the background of the concerned managers and professionals were identified. Thirdly, factors related to the particularities of the PRISMA-Experiment's governance were noted. Our experience leads to consider time as the answer to these hindering contextual, professional and governance issues.
These observations hold an important strategic value in a time where a wider integration experimentation is planned by the ‘plan-Alzheimer’ in France.
PMCID: PMC2807061
integration measurement; factors influencing implementation; integrated health care networks; France
7.  The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly 
BMC Family Practice  2012;13:115.
With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.
The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.
The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.
Trial registration
The CareWell-primary care study is registered in the Protocol Registration System: NCT01499797
PMCID: PMC3527269  PMID: 23216685
Frail elderly; Complex intervention; Integrated care; Functional status; Cost-effectiveness; Implementation; Process evaluation; Primary care
8.  Integrated care as a priority of the Basque Strategy for Chronic Diseases: the Bidasoa Integrated Healthcare Organisation 
The Basque Department of Health released in 2010 the “Strategy for tackling the challenge of chronicity in the Basque Country”. One of its five priority policies is contributing to the continuity of care for chronic patients. A key strategic project is the development of new integration initiatives and pilots projects in the public Basque Health System. Five different integration projects are already in place, with the Bidasoa Integrated Healthcare Organisation as the flagship project.
The creation of the Bidasoa Integrated Healthcare Organisation as a public brand new organisation in January 2011 aims at integrating three primary care centres and their regional hospital of reference, covering a total population of 86,235 citizens.
Case description
The Bidasoa integration process is characterised by its shared leadership, with converging top-down and bottom-up initiatives, and collaboration between top-management and clinicians. The initiatives for integration are operating simultaneously at different levels: strategic (integrated strategic plan), financial (common budget and capitation payment), managerial (integrated clinical management agreements), processes (integrated care pathways, development of transitional care nursing, creation of polipathology unit), tools (stratification of the population, unification of electronic health record), and research (development of action-research pilots).
PMCID: PMC3184805
integrated care; chronic care; regional health systems; health policy
9.  Institutional integration, health and social care policy and social welfare: an application of the ‘path dependence’ theory in France 
The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. The PRISMA France study aims to investigate the implementation of this model, which relies on the establishment of advisory boards at institutional, organisational and professional levels of decision-making, in France. These boards are guided by whole systems thinking and function in a joined-up, co-ordinated manner.
A qualitative approach was adopted to study the model's implementation. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings and administrative documentations. Validity was insured by triangulation methods and content saturation.
Our analyses revealed the complexity, instability and fragmentation of the institutional governance of publics policies for elderly people. The ‘path dependence’ to the Bismarckian system and the incomplete reforms of gerontological policies generate a cohabitation of three concurrent policies (national, regional and local) and a juxtaposition of two institutional systems (health and social care policy and social welfare). In such a context, no institution possesses sufficient authority to determine gerontological policy.
In the light of these analyse, the particularly complex and time-consuming implementation of the PRISMA model in France can be better understood.
PMCID: PMC2807065
path dependency; public policies; integrated health care networks; France
10.  Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system 
Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.
We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.
The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.
A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.
PMCID: PMC2779811  PMID: 19917122
11.  Integrated care in Eindhoven, a challenge for healthcare providers, provider organizations and patients/clients 
To share experiences by discussing the necessity, the challenges and the used (implementation) strategies on integrated care.
Integrated care and chronic care by SGE will be described. SGE delivers with 260 professionals integrated primary healthcare, based on protocols, standards and disease programs for 80,000 people. There is a formalized and structural cooperation with hospitals, their specialists, social services and other organizations.
Because half of all the people with chronic illness have multiple conditions, SGE has taken interest in changing the management of diseases, such as heart failure, COPD, diabetes, depression. Deficiencies in current management and the transformation of health care from reactive to proactive are discussed. Approaches, methods and tools used by SGE are focused on. For example: the transition with the Chronic Care Model. This model summarizes the basic elements for improving health care in health systems at the community, organizations, practice and patient levels. Issues like implementation of chronic care programs and how SGE cooperates with the Maastricht University for evaluating outcomes of effectiveness of integrated care by SGE come up for discussion.
Data source
1. Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic applications and implications, a discussion paper. Int J Integr Care 2002 Oct–Dec;2:e12.
2. Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 2001;27:63–80.
3. Pater L, Dubbeldam S, Verweijen M. Implementeren, het speelveld in de praktijk. Lemma 2005.
4. Grol R, Wensing M, Eccles M. Improving patient care, the implementation of change in clinical practice. Butterworth-Heinemann 2004.
Preliminary conclusion
The multi-problem patients do need a change in health systems. Despite everything already done, there is still a long way to go. Local, national and international collaborations and networks therefore are a must.
Is the Chronic Care Model the model to make integrated care for frail elderly, patients with chronic care or long term care needs possible? The do's and the dont's in implementing integrated care.
PMCID: PMC2807094
chronic care model; multiple conditions
12.  A qualitative study of stakeholder views on the effects of provider payment on cooperation, quality of care and cost-containment in integrated stroke care 
Stroke services are a form of integrated care which have been introduced in many countries, including the Netherlands, to improve health outcomes and processes of care by connecting the acute, rehabilitative, and chronic phases of stroke care. Limited research exists on the effects of payment systems on the functioning of integrated care services from the perspectives of those involved in providing, planning and contracting the care. This qualitative study identified stakeholder views on i) challenges in integrated stroke care associated with fee-for-service systems; ii) other possible financing models for stroke care, and iii) challenges in the implementation of an integrated financing mechanism for stroke care.
Twenty-four participants were interviewed using face-to-face audio-recorded semi-structured interviews. Respondents were purposively selected from five stakeholder groups; care providers, health care managers, health insurers, experts and patient representatives. Transcribed data were coded and analysed to generate themes relating to the study aims.
Respondents mentioned the following challenges associated with the current fee-for-service system; inappropriate incentives for cooperation, efficiency and improving quality and the inability to exert steering power at the level of the stroke service. In addition, care is not patient-centred and the financing system is inflexible.
The respondents mentioned several solutions for the challenges, but there was no consensus amongst them. Regarding the implementation of integrated financing, respondents mentioned the following general challenges; a) the foundations of the financing system are incompatible with integrated financing, b) co-morbidity and c) the lack of evidence on the effect of integrated financing. Stroke-specific challenges were; a) the diverse patient population, b) a non-uniform care trajectory, c) unclear division of responsibility for the overall care and d) different stages of development among stroke services.
This study provides new knowledge on stakeholder perception of the effect of payment systems and financial incentives on cooperation processes, quality of care and cost-containment in integrated stroke care. The results show that fee-for-service does not provide the right incentives for the integration of stroke care. We recommend to perform financial experiments for integrated stroke care.
PMCID: PMC3623662  PMID: 23557401
Integrated care; Stroke; Payment system; Incentive; Fee-for-service; Cooperation
13.  Stakeholder cooperation 
Societies today are very complex. Effective and successful implementation of care policies is needed. The concept of stakeholder approach is about creating tools and instruments to organise the communication between all parties involved.
EASPD organised in 2006 the conference ‘ageing and disability—disabled people are ageing, ageing people are getting disabled’ in Austria. For the first time organisations from the care sector for ageing people and from the disability sector were working together to discuss their concepts and their experience and to develop strategies. In this conference main results of this cooperation will be analysed.
The care sector for elderly people in many countries is now facing the same problems as the disability sector 20 years ago: services are mainly medical oriented, the main solutions are care homes, services are social not right driven, the choice for individuals is very limited, … . We will come up with some suggestions to bridge the gap between the disability sector and the care sector in order to equalise the opportunities for elderly people with care needs.
PMCID: PMC2707585
equalisation of opportunities; stakeholder cooperation; choice; human rights
14.  L'examen médical périodique chez la personne âgée 
Canadian Family Physician  1984;30:601-604.
The general approach to prevention in elderly patients differs from that for younger patients. In the elderly, most of the preventive activites performed by family physicians are tertiary. Prevention and cure of disease often overlap. The major health problem in elderly patients is the development of progressive incapacity. The evaluation of risk factors for this condition is the principal purpose of the periodic health examination of these patients. This article summarizes the principal recommendations for the periodic health examination of the elderly and discusses barriers to their implementation.
PMCID: PMC2154205  PMID: 21279078
15.  Using Mobile Health to Support the Chronic Care Model: Developing an Institutional Initiative 
Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.
PMCID: PMC3523146  PMID: 23304135
16.  Institutional integration in France: Health Regional Agencies and integrated services delivery 
The PRISMA France pilot project is ongoing since 2006. This project aims to implement an integrated services delivery (ISD) for elderly people, based on the PRISMA methodology. The experimentation is coupled with an implementation study to identify factors that facilitate and hinder the implementation. The fragmentation of public authorities represents one of the first barriers identified.
In 2009, a large-scale institutional reform has been initiated. It consists of merging various structures having strategic authorities on medical and social care within a single entity: the Health Regional Agencies (HRA). One could anticipate that this reform should facilitate the implementation of ISD.
To analyze the influence of institutional reforms on a pilot program aiming to implement an ISD. In the framework of our qualitative study we analyze the way the actors conceive the HRA.
The potential to facilitate ISD of the HRA has been identified. It is hope that they should reduce the institutional fragmentation. Nonetheless, the link between these agencies and the implementation of ISD in the pilot project was rarely made.
The extent of institutional change is bought into question by the past of the French system of social welfare.
PMCID: PMC3031844
integrated networks; PRISMA; implementation study; institutional fragmentation; Regional Agencies of Health
17.  Interventions psychothérapeutiques auprès de personnes âgées déprimées. 
This article reports the development of our research interests in the field of clinical practice in gerontology, in particular with people suffering from depression during the last five years. It summarizes the progression of our work in four domains: the coping strategies of elderly people with respect to depression, the assessment of depressive symptomatology, the psychotherapy with elderly people who are depressed (in particular the cognitive-behavioral intervention in groups), and the preparation of elderly people to the psychotherapeutic intervention. The article ends with some suggestions for research and clinical practice.
PMCID: PMC1188326  PMID: 1958652
18.  Is leadership and management in inter-agency settings really that different? Perspectives from the literature 
Health and social care collaboration is currently a key feature of improvement efforts internationally. Moreover, leadership is increasingly considered an important driver in terms of organisational performance, in particular in relation to the implementation of policy designed to solve the wicked issues of society. Yet, despite leadership being viewed as an essential component of integrative public sector performance, there is relatively little thoughtful work analysing the relationship between the two sets of ideas. Leadership in collaborative settings is simultaneously represented as being both the same, and yet different, to these roles in more traditional settings. What this means in practice is that much of the literature appears somewhat at best platitudinous and at worst confused—posing practical difficulties for leaders and managers of collaborations who are looking for evidence or guidance on how to enact leadership.
Aims and objectives
This paper examines the literature and asks how different leadership in inter-agency settings is from more ‘traditional’ settings, before going on to map out lessons which may be useful for leaders and managers to draw upon in more effectively navigating this difficult terrain.
This research is based on an extensive review of the literature surrounding leadership, collaboration and broader theories of networks.
The paper finds that this distinction is overstated; there are also significant overlaps in the types of tasks and challenges that both sets of leaders and managers will face and these should not be underestimated.
This has clear implications for training and development of these individuals where understanding of the contexts for and nature of partnerships—and thus the sensemaking and performance that may be most effective—may be as important as the skills and attributes themselves.
PMCID: PMC2430278
literature study; leadership; network theory
19.  Dissemination: Bringing Translational Research to Completion 
Despite the availability of innovative health care research, a gap exists between research-generated knowledge and the utilization of that knowledge in real-world practice settings. This article examines the transition from research to implementation in the context of the dissemination of A. Jean Ayres’ sensory integration procedures and of the challenges currently facing the University of Southern California Well Elderly Studies research team. Drawing from the emerging field of implementation science, this article discusses how researchers can develop an implementation plan to more easily translate evidence into practice. Such plans should address the intervention’s reach (i.e., its capacity to penetrate into the intended target population), the settings for which it is applicable, the leaders who will encourage practitioner uptake, stakeholder groups, and challenges to dissemination. By taking action to ensure the more effective dissemination of research-generated knowledge, researchers can increase the likelihood that their interventions will lead to improvements in practice and more effective care for consumers.
PMCID: PMC3722656  PMID: 23433273
diffusion of innovation; evidence-based practice; information dissemination; translational medical research
20.  The Dutch National Care for the Elderly Programme: integrated care for frail elderly persons 
The Netherlands Organisation of Health Research and Development (ZonMw) has launched the ambitious National Care for the Elderly Programme to improve care and support for frail elderly persons. This four years programme (2008–2011) is initiated by the Ministry of Health, Welfare and Sport. The budget is 80 million euro.
The programme consists of three steps. First, regional networks were formed consisting of all parties that can contribute to the organisation of care and support for frail elderly persons. Second, innovative experiments were formed within these networks. These experiments focus on a reorganisation and integration of care and support and are formally evaluated. They should lead to added value for elderly people, in terms of greater self-reliance, better retention of function, and reduced care use and treatment burden. The third step is dissemination and implementation of knowledge.
Eight networks are formed and continue to grow. These networks developed 13 experiments on the following topics: screening of frailty, reactivation after hospitalisation, improvement of primary care, integrated care, and new information systems. More experiments will follow.
We aim for better integrated care and added value for frail elderly persons through formation of networks and experiments. Whether this approach works is still to be tested.
PMCID: PMC3031815
frailty; elderly people; networks; Netherlands
21.  The NIHR collaboration for leadership in applied health research and care (CLAHRC) for greater manchester: combining empirical, theoretical and experiential evidence to design and evaluate a large-scale implementation strategy 
In response to policy recommendations, nine National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) were established in England in 2008, aiming to create closer working between the health service and higher education and narrow the gap between research and its implementation in practice. The Greater Manchester (GM) CLAHRC is a partnership between the University of Manchester and twenty National Health Service (NHS) trusts, with a five-year mission to improve healthcare and reduce health inequalities for people with cardiovascular conditions. This paper outlines the GM CLAHRC approach to designing and evaluating a large-scale, evidence- and theory-informed, context-sensitive implementation programme.
The paper makes a case for embedding evaluation within the design of the implementation strategy. Empirical, theoretical, and experiential evidence relating to implementation science and methods has been synthesised to formulate eight core principles of the GM CLAHRC implementation strategy, recognising the multi-faceted nature of evidence, the complexity of the implementation process, and the corresponding need to apply approaches that are situationally relevant, responsive, flexible, and collaborative. In turn, these core principles inform the selection of four interrelated building blocks upon which the GM CLAHRC approach to implementation is founded. These determine the organizational processes, structures, and roles utilised by specific GM CLAHRC implementation projects, as well as the approach to researching implementation, and comprise: the Promoting Action on Research Implementation in Health Services (PARIHS) framework; a modified version of the Model for Improvement; multiprofessional teams with designated roles to lead, facilitate, and support the implementation process; and embedded evaluation and learning.
Designing and evaluating a large-scale implementation strategy that can cope with and respond to the local complexities of implementing research evidence into practice is itself complex and challenging. We present an argument for adopting an integrative, co-production approach to planning and evaluating the implementation of research into practice, drawing on an eclectic range of evidence sources.
PMCID: PMC3170237  PMID: 21861886
22.  EHR Safety: The Way Forward to Safe and Effective Systems 
Diverse stakeholders—clinicians, researchers, business leaders, policy makers, and the public—have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.
PMCID: PMC2409999  PMID: 18308981
23.  L'utilisation de services de santé et de médicaments par des personnes âgées de Montréal qui reçoivent des soins maintien à domicile. 
Canadian Medical Association Journal  1981;124(9):1168-1171.
A survey was conducted among 160 persons aged 64 year or more in Montreal who were receiving home care. They answered at home a questionnaire on their use of health care services and drugs, and showed the interviewer all the drugs they were taking. In comparison with similar data from elsewhere, the use of health care services (an average of 8.0 encounters with a physician per person per year) and of drugs (an average of 5.3 per person) by this group seems high. Perhaps this group of people was obviously sicker than others of the same age, but this remains to be shown. Moreover, despite the reported frequency of health problems, it is uncertain whether such use of services and drugs was necessary. The question is raised whether the home care system is doing for the patient what it was intended to do.
PMCID: PMC1705319  PMID: 7237337
24.  Peut-on se permettre de ne pas évaluer les services offerts aux personnes démentes? 
Canadian Family Physician  1990;36:1761-1769.
With the increasing expenditure on health care programs for seniors, there is an urgent need to evaluate such programs. The Measurement Iterative Loop is a tool that can provide both health administrators and health researchers with a method of evaluation of existing programs and identification of gaps in knowledge, and forms a rational basis for health-care policy decisions. In this article, the Loop is applied to one common problem of the elderly: dementia.
PMCID: PMC2280520  PMID: 21233998
25.  L'agitation chez la personne âgée. Approche diagnostique et thérapeutique. 
Canadian Family Physician  1996;42:2392-2398.
Treating agitation in elderly people is a complex process. Faced with a paucity of empirical information, clinicians tend to adopt a therapeutic approach based on their clinical evaluation. This article offers a rational approach that will help physicians to better understand, evaluate, and treat agitation.
PMCID: PMC2146864  PMID: 9004893

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